Service Dog Application

Service Dog Application

Please fill out this form to submit your application for a service dog with us.
CLIENT INFORMATION
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Occupation*
Date of Birth*
Martial Status*

SingleDivorcedMarriedOther
Please explain
Do you already have a dog you want to use?*

YesNot
Dog’s name*
Dog’s age*
Dog’s breed or breed mix*
How long have you had the dog?*
Has the dog had any formal training? If yes, where? What kind of training? (basic obedience, etc) What training methods were used? (positive reinforcement, shock collar, boot camp, training collar, etc)*
Which program are you applying for?*

Private TrainingPrison ProgramNot sure
PERSONAL INFORMATION
Type of Home*

HouseApartmentCondoOther
How many family members are in the home?*
Do you have a good support system?*

YesNo
Please list all persons who live in the home (NAME, AGE, SEX)*
Are there other pets in the home?*

YesNo
Please list all other pets who live in the home (NAME, SPECIES, AGE, SEX)*
Give an example of a typical day for you:*
Places you frequently go:*
How do you best learn?*

ListeningReadingDoing
Are you currently employed?*

YesNo
Employer name
Supervisor’s name and phone number
Reponsibilities
Work schedule (Days / hours worked)
MEDICAL INFORMATION
How is your overall health?
Do you:

Drink alcohol?Smoke?Take illegal drugsTake prescribed drugs?
Primary Physician
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Other Physicians you see for your disability:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Other Physicians you see for your disability:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Has your physician recommended you need a service dog?

YesNo
Disability/Diagnosis?
Is your disability:

ProgressiveStable
How does your disability affect you/your life?
Physical or mental limitations:
Medications you take
Side effects you experience from medications you take:
Current therapies/treatments being used:
Will there be a third party handler?

YesNo
If there will be a third party handler please list their name, age and relation to you:
What do you need the dog to be able to do for you? (task work)
Is there anything else you would like us to know when considering your application for a service dog?
By signing below, you are confirming that the information provided above is accurate, complete and up to date.
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Service Dog Application

CLIENT INFORMATION

PERSONAL INFORMATION

MEDICAL INFORMATION